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A leading US Senator has called for drug patent "monopolies" to be abolished and replaced by an annual prize fund to reward the discovery of new treatments which would then, because of the power of competitive markets, become available at the lowest possible price.

"The US has - by far - the highest prices in the world for prescription drugs," says Vermont's Independent Senator, Bernie Sanders. "The simple fact is that the prices of patent medicines are a significant barrier to health for millions of uninsured and underinsured Americans, and people die because of it," he added, opening a hearing held by a subcommittee of the Senate Health Education, Labour and Pensions (HELP) Committee last week.

What drives up US prices is the government patent system that grants monopolies to pharmaceutical companies that develop new drugs, Sen Sanders told the hearing, held by the panel's subcommittee in primary health and ageing, which he chairs. As far as he knew, he said, this was "the first Congressional hearing ever held to discuss the possibility of ending monopolies for medicines and offering a serious proposal to replace our broken system with one that would accelerate innovation while providing virtually universal access to life-saving medicines."

Sen Sanders says that while this concept is relevant to all kinds of diseases, he has introduced Senate bill 1138, the Prize Fund for HIV/AIDS Act, which would de-link R&D incentives from drug prices specifically for new HIV/AIDS medicines and create instead a $3 billion annual prize fund to reward the discovery of new treatments.

One of the reasons he decided to focus the bill on a single disease was what he discovered about the price of Bristol-Myers Squibb/Gilead's HIV/AIDS drug Atripla, which combines three medicines - Sustiva (efavirenz), Emtriva (emtricitabine) and Viread (tenofovir disproxil fumarate) - which, he said, "simply blew me away."

Atripla costs more than $25,000 per person per year in the US, but the generic version, which is approved by the Food and Drug Administration (FDA) but unavailable for sale in the US, costs less than $200 per patient per year, he said. The generic version is being purchased from a competitive supplier by the President's Emergency Plan for AIDS Relief (PEPFAR), for under $200 per patient a year, for distribution in developing countries, Sen Sanders told the hearing.

The $3 billion annual prize fund proposed in his bill would make awards to developers of medicines, based primarily upon therapeutic value a new treatment offers and the number of people it benefits. Products would have generic competition immediately after FDA approval - the bill would eliminate "today's high-priced marketing monopolies as the reward for patented medical innovations," he said.

The $3 billion-a-year fund would pay for itself, "and then some," said Sen Sanders. When you compare this cost to the savings which would be realised by paying generic prices for the estimated $9.7 billion paid in the US last year on the top 15 brand-name HIV/AIDS drugs, before rebates or discounts, "it's a bargain," he said.

Sen Sanders' bill is supported by Joseph Stiglitz, winner of the Nobel Prize in Economics and a chief economist for the World Bank. "America is the most innovative country in the world. It has the best universities, attracting the best minds from around the world. But America also has the least efficient health care system in the world, spending more money per capita and a larger fraction of Gross Domestic Product (GDP) on the health care system than any other country - and getting far poorer outcomes than countries that spending much less," he said.

"We need to harness our innovation system to work to drive down the costs and to improve performance, Prof Stiglitz told the hearing, adding that the approach taken by Sen Sanders' bill is "exactly right" and "will provide a model for further reforms in our health innovation system."

That could be the slogan for a radical idea that leading economists say would lower the price of new drugs for treating HIV/AIDS.

(Manuel Balce Ceneta/AP) - Sen. Bernard Sanders (I- Vt.), has introduced a bill to establish a prize system for the development of anti-AIDS drugs.

Treating AIDS costs tens of thousands of dollars per patient annually in the United States, and more and more patients are unable to afford the life-saving drugs, according to figures from the AIDS Drug Assistance Program. The waiting list for the program, which is jointly funded by federal and state governments and provides medicines to low-income patients, now stands at 2,759, up from 361 in 2010.

Academics have been saying for more than a decade that one way to lower drug costs would be to offer pharmaceutical companies a share of a multi-billion-dollar prize pool, instead of the current system of patents that give a company exclusive rights to newly developed drugs.

The notion surfaced in Congress last week at a hearing called by Sen. Bernard Sanders (I-Vt.), who has introduced a bill to establish a prize system for the development of anti-AIDS drugs.

"It simply blew me away - and would blow anyone's mind away - that one drug, Atripla, costs $25,000 per year" in the United States, Sanders said at the hearing of the subcommittee on primary health and aging.

Generic versions of the same drug cost $200 in Africa and other parts of the developing world.

The huge price gap is a result of a deal struck with brand-name U.S. drugmakers under the President's Emergency Plan for AIDS Relief, which provides anti-retroviral drugs to 3.9 million people in developing countries. In 2003, to reach more patients, brand-name drugmakers agreed to let overseas drugmakers sell generic, low-cost versions of their patented AIDS drugs outside the United States.

Under Sanders's bill, newly developed AIDS drugs could immediately be made by any drug company as a low-cost generic. In lieu of patent protection, the company that invented the drug could win a prize from a pool funded by insurance companies and the federal government at $3 billion per year.

To win, companies would have to show that a drug performed better than older drugs. A panel of experts would evaluate claims.

If enacted, the bill would save private insurers, Medicaid and other government assistance programs money , Sanders said. Acknowledging that the plan would reduce drug company profits, he called it "fairly radical for the U.S. Congress."

"This is like the nuclear option for the pharma sector," said James Love, an intellectual property expert who testified in favor of the bill.

While Sanders acknowledged that the legislation isn't going anywhere anytime soon - he is its sole sponsor - the idea of prizes to speed new medicines to market is gaining momentum.

Nobel Prize-winning economist Joseph Stiglitz and Harvard Law professor Lawrence Lessig testified in favor of the bill, and last month, an advisory committee to the World Health Organization broadly endorsed prizes for drug development. Via other legislation, Congress is poised to ask the U.S. National Academies to study the issue.

Hearing on HIV/AIDS Legislation:

On May 15, 2012, the Subcommittee on Primary Health and Aging of the Senate HELP Committee convened to take testimony on why many people diagnosed with HIV/AIDS cannot afford the medications they need. Chairman Bernard Sanders said his bill, S. 1138, would create a $3 billion prize fund to award developers of HIV/AIDS drugs offering added therapeutic value. Witnesses testified on current barriers, including the rapid increase in HIV drug regimens and inefficiencies in the U.S. patent system for drug products.

Witnesses included the following individuals - and a link to their testimony posted on the HELP Committee site below:

A leading US Senator has called for drug patent "monopolies" to be abolished and replaced by an annual prize fund to reward the discovery of new treatments which would then, because of the power of competitive markets, become available at the lowest possible price.

"The US has - by far - the highest prices in the world for prescription drugs," says Vermont's Independent Senator, Bernie Sanders. "The simple fact is that the prices of patent medicines are a significant barrier to health for millions of uninsured and underinsured Americans, and people die because of it," he added, opening a hearing held by a subcommittee of the Senate Health Education, Labour and Pensions (HELP) Committee last week.

What drives up US prices is the government patent system that grants monopolies to pharmaceutical companies that develop new drugs, Sen Sanders told the hearing, held by the panel's subcommittee in primary health and ageing, which he chairs. As far as he knew, he said, this was "the first Congressional hearing ever held to discuss the possibility of ending monopolies for medicines and offering a serious proposal to replace our broken system with one that would accelerate innovation while providing virtually universal access to life-saving medicines."

the end

This wasn't added but this is what I think.

The prices are ridiculously high and it is about time the were brought back down to real cost. Not $1500/mth but $25/mth.

"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

"The simple fact is that the prices of patent medicines are a significant barrier to health for millions of uninsured and underinsured Americans, and people die because of it," he added, opening a hearing held by a subcommittee of the Senate Health Education, Labour and Pensions (HELP) Committee last week.

Well obviously this is true. But also what cannot be said in this climate is that European countries ALSO pay top retail prices, and yet find money in their budgets to treat people who need HAART.

So yes in a pollyanna world the 1st world price could fall and every budget would get some relief, but where is the commitment of "the richest and greatest country in the world" to figure out universal coverage now.....

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“From each, according to his ability; to each, according to his need” 1875 K Marx

Well obviously this is true. But also what cannot be said in this climate is that European countries ALSO pay top retail prices, and yet find money in their budgets to treat people who need HAART.

So yes in a pollyanna world the 1st world price could fall and every budget would get some relief, but where is the commitment of "the richest and greatest country in the world" to figure out universal coverage now.....

Just as an FYI, Switzerland is not a particularly good proxy for the cost of health care in Europe or the relative cost of drugs. Switzerland is typically the second or third-highest spender on healthcare as a percent of GDP (although down by a long ways compared to the US) among the OECD / 1st world countries. And because its healthcare system features competing insurers much like the US system will if Obamacare remains in effect, it tends to pay higher prices for things like drugs compared to other OECD countries.

Which does not disrupt your main point -- the US should keep going and move over to a new health care system. The underfunding of ADAP is a national shame and puts people's health at risk. It also harms worker mobility and increases long term deficits. Just...Switzerland is not a great example of efficient health care either.

Just as an FYI, Switzerland is not a particularly good proxy for the cost of health care in Europe or the relative cost of drugs. Switzerland is typically the second or third-highest spender on healthcare as a percent of GDP (although down by a long ways compared to the US) among the OECD / 1st world countries. And because its healthcare system features competing insurers much like the US system will if Obamacare remains in effect, it tends to pay higher prices for things like drugs compared to other OECD countries.

Which does not disrupt your main point -- the US should keep going and move over to a new health care system. The underfunding of ADAP is a national shame and puts people's health at risk. It also harms worker mobility and increases long term deficits. Just...Switzerland is not a great example of efficient health care either.

Yep all true. And it does not contradict my minor point either. That the USA might be able to better deal with misc social and economic challenges by dropping the "American Exceptionalism" and just doing the normal, average, non-imperial, mundane things any other rich country would do, in many situations. Its this idea that some brilliant SPECIAL solution or action must be achieved because it is after all The US of Amercia. And sometimes the idea that nothing needs fixing, because after all its already the greatest and any criticism must be anti-American and unpatriotic.

My shoddy history seems to remember that Hillary Clinton proposed pretty much the Swiss model of private insurance with universal coverage when she was laughed off the Hill.

It was a minor point, really. But it seems elected congress in both parties can't get away from the hyperbole. Greatest Nation. Richest Nation. Nation with most Freedoms. Nation where everyone can become Bill Gates (or President, etc.). Best Higher Education. Best Health Care. blah de be blah blah blah. Meanwhile... around the world, other nations are solving or avoiding crisis in all these areas.

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“From each, according to his ability; to each, according to his need” 1875 K Marx

The main point is that Big Drug Business had gotten away with this corrupt skim of exorbitant prices for HIV medication which without government funding, no one but the rich can afford. In the end, to pay for these drugs comes from Medicaid, Medicare and Social Security; hence, directly or indirectly the money comes from taxes. I hate to get all "Conspiracy Theory" on You, but this looks like a well laid plan to get an enormous amount of money with the excuse of funding for research. The time is now to fight the GREED and bring back the drug prices to where they should be. Not $2500 a month but to $25 a month. Yeah one can say that without the huge profits there would be no money for research but let to make profits with a strangle hold on people, places and countries that can't afford it is just too "totalitarian" or "1984ish” for me or anyone. The time is now to take away the power that big drug business has on government; in addition, to capped drug prices to what ordinary people/citizens can afford.

Seems like in a rich country, 2000 a month might rather seem more reasonable at 200.00 a month.

The companies are already cutting deals for their drugs, now sold at 1/100 of the rich country price, to poor countries, or providing the patent lease to Indian for example so that country can manufacture generics.

Not sure I understand this argument of taxes paying for the HAART. This REALLY depends on the country. In the USA, what is the percentage of people on HAART being paid for by their insurance companies and what is the percentage of those on HAART being paid for by social safety nets. What is the price of a year of HIV treatment compared to other chronic diseases?

Also just as a comparison, if Switzerland was/is the model for 100 coverage but 100 private insurance companies covering, then my Swiss taxes are NOT paying for my or anyone's HAART. I now cost more to my Insurance company which spreads the cost out to all the people who pay premiums to the company.

Rich countries with socialized medicine paying near top dollar would seem to be the place where tax payer arguments have grip - but only if the price of HIV treatment can be proven to be exhorbitant in comparison to other drug treatments... What drug treatment should it be compared to? When have the companies profitted enough from a admittedly brilliant drug response to a hideous, fatal disease.... Interesting questions.

« Last Edit: June 07, 2012, 08:53:57 AM by mecch »

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“From each, according to his ability; to each, according to his need” 1875 K Marx

The main point is that Big Drug Business had gotten away with this corrupt skim of exorbitant prices for HIV medication which without government funding, no one but the rich can afford. In the end, to pay for these drugs comes from Medicaid, Medicare and Social Security; hence, directly or indirectly the money comes from taxes.

Average middle class INSURED people in the USA "afford" HAART through their insurance benefits with private insurance.

Otherwise, agreed, the prices are exhorbitant! And in a global framework, obviously only rich people or rich countries can afford the higher retail prices, as opposed to the discount prices.

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“From each, according to his ability; to each, according to his need” 1875 K Marx

then is the 2000 USD a month to keep a person healthy "exhorbitant?" or not... I would say it is very expensive, yes. Drive harder bargains with drug companies....

But "conspiracy" is another name for widespread military, industrial, financial, and every other industry, "bilking" the government in mutually beneficial ways. Average people lost their homes in the financial crisis, the banks had a minor bump and are back on record profits for some time now.... Surely the US gov cuts slimy deals with pharma... As it does with every other big industry?

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“From each, according to his ability; to each, according to his need” 1875 K Marx

It occurs to me a outlier thought.....Well for example that documentary about HIV in the deep south and leatherman's constant reminders about the perilousness of safety net funding of HIV treatment in the USA...Griping about he high cost of HAART might seem perfectly logical to people who HATE hiv+ people. I mean, are we worth the price??? Obviously not worth it, in many people's minds.... I sure do wonder what VOODOO magic Bono cast on Jesse Helms for his somewhat turnaround on his hatred of homosexsicles in Amercia. I guess that it was gonna be "cut rate" HAART helped a lot.

Sure it's expensive. L'Oreal. HAART. Je le vaux bien.

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“From each, according to his ability; to each, according to his need” 1875 K Marx

You might find this article interesting. Here's one interesting paragraph and a link to the article, which appeared in multiple publications.

If the process of developing HIV drugs has been unusual, selling them has been even more so. America is the rich world's biggest market, with 841,000 patients diagnosed. More than 60 percent of HIV drugs in America are bought with public money. Insurers give HIV special treatment, and patients are rarely pressed to buy the cheapest pills, as they might be if they had another disease.

The business of HIV: Better drugs, but at high costArticle by: THE ECONOMIST Updated: June 3, 2012 - 3:43 PM

FDA is poised to approve use of a drug to prevent HIV transmission.

The coming weeks might bring a major victory in the long war against the human immunodeficiency virus, aka HIV, which causes AIDS. A drug called Truvada already treats the disease. By June 15, American regulators are expected to approve its use to prevent the transmission of HIV as well.

The past 30 years have produced several triumphs. A flood of money has helped scientists to invent new drugs and helped health workers to deliver them to those in need. These drugs have transformed a fatal disease into a chronic one. They also have made HIV a big business.

Sales of antiretroviral drugs in America and the five biggest European markets reached $13.3 billion in 2011, according to Datamonitor, a research company. The market is as unusual as it is large, both buoyed by government support and worryingly dependent on it. The past decade has brought fancier medicine in rich countries and copious aid for poor ones, but the war is far from won.

Publicly funded research has played a larger role in developing drugs for HIV than for other diseases. A study published last year in Health Affairs found that HIV drugs are three times as likely to involve a patent from the public sector. HIV also has special status among regulators: America's Food and Drug Administration created a faster way to review HIV drugs, for example, allowing them on the market before the most expensive stage of clinical trials.

In total, public and private investment has yielded more than two dozen HIV drugs. In 1987 Burroughs-Wellcome, now part of Glaxo Smith Kline, introduced the first one, tackling an enzyme that helps the virus progress inside human cells. In 1995 Hoffmann-La Roche, a Swiss drug firm, launched the first protease inhibitor, which interrupts the virus at a later stage of replication.

Today different medicines are combined to suppress resistance or reduce side effects. The rise of combination therapy has brought a flurry of cross-licensing, as companies strike deals to sell each other's drugs in carefully calibrated cocktails.

One company stands out: Gilead. A late entrant to the HIV race, the California firm quickly took the lead. Its strategy was simple: The more convenient the treatment, the better. In 2004 Gilead launched Truvada, a once-a-day, one-pill combination of two drugs. In 2006 it introduced Atripla, a once-a-day, one-pill combination of Truvada and another treatment. Atripla's average wholesale price in America is nearly $25,000 per patient, per year. In 2011 its global sales reached $3.2 billion.

More good news for Gilead has come in recent weeks. An FDA panel recommended Truvada for preventive use, to protect healthy people from contracting the virus. Another FDA panel endorsed Gilead's new Quad pill, which is the simplest, most effective combination drug to date.

If the process of developing HIV drugs has been unusual, selling them has been even more so. America is the rich world's biggest market, with 841,000 patients diagnosed. More than 60 percent of HIV drugs in America are bought with public money. Insurers give HIV special treatment, and patients are rarely pressed to buy the cheapest pills, as they might be if they had another disease.

Distributing drugs in poor countries is harder. A decade ago hardly any poor people could afford them. At first drug companies handled this badly. In 1998, 39 big Western firms sued South Africa to protect their HIV patents. Global uproar ensued, and the firms backed down in 2001. Then two things changed.

First, rich countries started donating vast sums to fight AIDS in poor ones. In 2000 there was less than $2 billion for HIV programs each year. By 2010 there was $15 billion, thanks to the Global Fund to Fight AIDS, Tuberculosis and Malaria and George W. Bush's President's Emergency Plan for AIDS Relief.

Second, the price of AIDS drugs plunged. In May 2000, a year's "triple cocktail" therapy cost $10,000 or so. By 2011 the same pills sold for $62 in poor countries. The Plan for Aids Relief buys generic versions of patented drugs, which may be supplied only to poor countries.

Can treatment expand further? Despite the subsidies and the plunge in prices, less than half of those infected with HIV take HIV drugs. Those who do, however, live a long time, and they have to keep taking the pills. What's more, new studies show that it helps to start treating patients early, so demand is sure to rise.

Alas, aid dipped in 2009 and 2010 because of the financial crisis. To make matters more complicated, there is a trade-off between more drugs and better ones: Most patients in poor countries get outdated pills, according to Medecins Sans Frontieres.

Allowing generics firms to copy even more patented drugs might help. Since 2006 Gilead has licensed drugs to generics firms for 5-percent royalties. Last year it went further, agreeing to license drugs to a "patent pool" to centralize royalty deals for a range of companies.

Even in rich countries, public willingness to pay for the best drugs may be waning. Express Scripts manages drug costs for American employers. With Gilead's expensive Quad poised to enter the market, employers have started asking Steve Miller, Express' chief medical officer, to contain HIV costs, possibly by nudging patients toward cheaper drugs.

I really didn't like the tone of that article and thought it seemed to miss some major points of WHY things are the way they are.

Quote

HIV also has special status among regulators: America's Food and Drug Administration created a faster way to review HIV drugs, for example, allowing them on the market before the most expensive stage of clinical trials.

that happened because the death rate was so high and because so many activists demanded the government step in to help stop the tide of death. thank goodness this happened or there would have been many more AIDS deaths, and they would have continued into the early 2000s

Quote

If the process of developing HIV drugs has been unusual, selling them has been even more so. America is the rich world's biggest market, with 841,000 patients diagnosed.

there are other diseases in America with more patients, so this reads like an inflated boast. Cancer has been a much "bigger market" with it's expensive chemo and many more patients (which have included people with HIV)

Quote

More than 60 percent of HIV drugs in America are bought with public money.

due to HIV's relationship to poverty and risky behaviors in the first place along with the sickness/disability that it often brings, not to mention the price of treatment and/or hospitalization, is it any wonder HIV wipes out many people's ability to care for themselves forcing them to rely on government assistance for their daily life-sustaining medications?

Quote

Insurers give HIV special treatment, and patients are rarely pressed to buy the cheapest pills, as they might be if they had another disease.

until recently there were no generic medications yet (the patents were still in effect) and the few that are off patent now are not very effective and therefore less used. This statment was a poor comparison because there really aren't any "cheap pills to use that if this was another disease".

Quote

Second, the price of AIDS drugs plunged. In May 2000, a year's "triple cocktail" therapy cost $10,000 or so. By 2011 the same pills sold for $62 in poor countries.

apples and oranges again. This is an incorrect comparison trying to correlate the economies of America vs. third-world countries. when comparing average income of $30k a year to $300 a yr the relative price of the medications is nearly the same.

It occurs to me a outlier thought.....Well for example that documentary about HIV in the deep south and leatherman's constant reminders about the perilousness of safety net funding of HIV treatment in the USA...Griping about he high cost of HAART might seem perfectly logical to people who HATE hiv+ people. I mean, are we worth the price??? Obviously not worth it, in many people's minds.... I sure do wonder what VOODOO magic Bono cast on Jesse Helms for his somewhat turnaround on his hatred of homosexsicles in Amercia. I guess that it was gonna be "cut rate" HAART helped a lot.

Sure it's expensive. L'Oreal. HAART. Je le vaux bien.

It sort of reminds me of the quote from "Wall Street" that went,"Greed is Good." It is like the whole pursuit is to gather a "s&#t load of money, as much as you can, (now I'm thinking of the mathematical model for maximum profit), to hell with ideology and pay off the mortgage. Be it cancer drugs, malaria drugs, TB or what have you. Side note: Didn't the guy who found the cure for measles gave away the patient which saved countless of lives? The point is, it's a DRUG WAR where the loser are the ones that can't afford the cost and the winners, profit-mongers, are fat and happy and "living the lifestyles of the Rich and Famous."

I really didn't like the tone of that article and thought it seemed to miss some major points of WHY things are the way they are.that happened because the death rate was so high and because so many activists demanded the government step in to help stop the tide of death. thank goodness this happened or there would have been many more AIDS deaths, and they would have continued into the early 2000sthere are other diseases in America with more patients, so this reads like an inflated boast. Cancer has been a much "bigger market" with it's expensive chemo and many more patients (which have included people with HIV)due to HIV's relationship to poverty and risky behaviors in the first place along with the sickness/disability that it often brings, not to mention the price of treatment and/or hospitalization, is it any wonder HIV wipes out many people's ability to care for themselves forcing them to rely on government assistance for their daily life-sustaining medications? until recently there were no generic medications yet (the patents were still in effect) and the few that are off patent now are not very effective and therefore less used. This statment was a poor comparison because there really aren't any "cheap pills to use that if this was another disease".apples and oranges again. This is an incorrect comparison trying to correlate the economies of America vs. third-world countries. when comparing average income of $30k a year to $300 a yr the relative price of the medications is nearly the same.

Some of you points are valid, other are nick picky with good reason, but the point is the cost of medications are high because they can keep it high. They could sell it at a lower cost, but they don't have to. This is a major "Kool-Aid" moment where they have the public believing what they want them to believe and therefore, keep the ball rolling. That's right, we are "Drinking the Kool Aid."

Some of you points are valid, other are nick picky with good reason, but the point is the cost of medications are high because they can keep it high. They could sell it at a lower cost, but they don't have to. This is a major "Kool-Aid" moment where they have the public believing what they want them to believe and therefore, keep the ball rolling. That's right, we are "Drinking the Kool Aid."

Got me wondering... just how do people without healthcare but still working afford or get their meds? Say you work earning $25,000 - $30,000 (gross) a year, buying your car, your house, and other living expenses. I can't imagine paying $2000+ a month out of pocket for meds. And from what I have read, you have to be property level to get help. So are people forced to stop working and live on government assistance (which can take years to actually get)? Are there other programs to assist people that still work and have income but not near the Mitt Romney level of wealth?

Usually we hear of two groups of people, one on SSDI, and the other still working with employer medical insurance. But how about those in-between?Just wondering....

just how do people without healthcare but still working afford or get their meds?

many people get their meds through the ADAP (AIDS Drug Assistance Program) administered as part of the Ryan White Act. However being a state-administered program, each state tends to have it's own formulary of HAART and other meds and it's own FPL standard for eligibility. ADAP mainly either provides outright or meds or it pays someone's insurance premium.

And that's why the ADAP waiting list issue is so important. Many of the people using ADAP continue working, paying taxes, and essentially paying for their own healthcare. Without access to meds (because there are not enough state ADAP funds to assist them), ASOs and other agencies have to scramble to help out, or people simply go without meds until they get so poor - and so sick - that government assistance (like medicaid and medicare) can step into to help.